guidance for care homes sample · introduction 4 2. infection ... (standard precaution) 4. hand...
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Guidance for Care Homes
1
Name
Job Title
Preventing
Infection
WorkbookGuidance for Care Homes
10th Edition SAMPLE
Guidance for Care Homes
3 Co
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Contents Page Tick when completed
1. Introduction 4
2. Infection prevention and control 5
3. Standard precautions 10
4. Hand hygiene 11
5. Personal protective equipment 17
6. Sharps management 21
7. Blood and body fluid spillages 25
8. Waste management 29
9. Laundry 32
10. Decontamination of equipment 35
11. Environmental cleanliness 39
12. Aseptic technique 41
13. Specimen collection 45
14. Preventing a UTI 49
15. Urinary catheter care 53
16. Viral gastroenteritis/Norovirus 57
17. Clostridium difficile 61
18. MRSA 65
19. MRGNB 69
Commentary 73
Key references 74
Certificate of completion 75
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1. Introduction As an NHS Community Infection Prevention and Control (IPC) Team
based in North Yorkshire, our aim is to support care homes in
promoting best practice in infection prevention and control. This
Workbook complements a range of educational infection prevention
and control resources which can be viewed at
www.infectionpreventioncontrol.co.uk.
This Workbook is intended to be the foundation for best practice for
infection prevention and control. By applying the principles within the
Workbook, you will demonstrate commitment to high quality care and
patient safety. The Francis Report 2013 states “It is unacceptable for
a patient to be injured by contracting certain types of infection as a
result of the failure to apply methods of hygiene and infection control
accepted by a specified standard-setting body, preferably NICE”.
The Workbook is aimed at all staff working in a care home, this
includes not only clinical staff, but all staff groups including
receptionists and cleaning staff.
The Workbook has been designed to be undertaken in stages. This
will allow you to complete the ‘Test your knowledge’ sections before
moving on to the next section. On completion, your manager will
check that you have achieved 100% competency in your infection
prevention and control knowledge and sign the ‘Certificate of
Completion’. You should keep the Workbook as evidence of learning
and as an on-going reference guide to provide you with easily
accessible advice for day-to-day care of residents.
The Workbook is evidence-based and includes the latest national
guidance. Completion of this Workbook also helps your organisation
demonstrate compliance with the Health and Social Care Act 2008
and the Care Quality Commission registration requirements in
relation to infection prevention and control training.
Dr Jenny Child
Director of Infection Prevention and Control/
Consultant Microbiologist
Harrogate and District NHS Foundation Trust
1.
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10 3.
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3. Standard precautions
There are seven control measures known as ‘Standard
precautions’ (see table below). These underpin routine safe
practice and break the chain of infection which in turn protects
residents, visitors and staff. There is often no way of knowing
who is infected, so by applying standard precautions to all
residents and at all times, best practice becomes second
nature and the risks of infection are minimised.
All care staff in all situations involving the care of residents or
contact with the resident’s environment, must use infection
prevention and control standard precautions.
In most cases, without a laboratory test, it is impossible to
tell who has or is carrying an infection. Since every person
is a potential infection risk, it is essential that all staff apply
safe systems of working at every opportunity.
Safe working practices take the guesswork out of
protecting yourself and others as you provide care.
7 standard precautions
Hand hygiene
Personal protective equipment
Sharps management
Blood and body fluid spillages
Waste management
Laundry
Decontamination of equipment 7 SAMPLE
Guidance for Care Homes
11 4. H
an
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4. Hand hygiene Evidence and national guidance identifies that effective hand
hygiene results in a significant reduction in the carriage of
harmful micro-organisms (germs) on the hands. Effective
hand hygiene decreases the incidence of healthcare
associated infection (HCAI) leading to a reduction in patient
morbidity (disease) and mortality (death).
Hand hygiene is the single most important way to prevent the
spread of infection. Hands may look visibly clean, but micro-
organisms are always present, some harmful, some not.
Removal of transient micro-organisms is the most important
factor in preventing them from being transferred to others.
Hands may become contaminated by direct contact with a
resident, handling equipment and contact with the general
environment.
Hand hygiene refers to the process of hand decontamination
where there is physical removal of dirt, blood, body fluids and
the removal or destruction of micro-organisms from the hands.
There are two categories of micro-organisms present on
the skin of the hands
Transient bacteria are found on the surface of the
skin. They are called ‘transient’ as they do not
routinely live on the hands. They are transferred to
hands after contact with residents or the environment
and are easily removed by routine handwashing with
liquid soap and warm running water.
Resident bacteria are found on the hands in the deep
layers and crevices and live on the skin of all people.
They play an important role in protecting the skin from
harmful bacteria and are not easily removed by
routine handwashing with liquid soap and warm
running water.
Tra
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Aprons
A single use disposable apron should be worn
whenever there is a risk of exposure to blood
and/or body fluids, non-intact skin, mucous
membranes or a known infection.
Aprons should also be worn when there is a risk of
soiling to the front of uniforms or workwear and before an
episode of direct ‘hands on’ care with a resident. Aprons
should be disposed of as soon as the activity is completed.
Glove selection guide Sterile Non-sterile
Procedure and type of contact
Aseptic technique
Blood/blood stained body fluids
Body fluids, e.g. urine, faeces
Decontamination of equipment
Domestic tasks
Sorting soiled laundry
Urinary catheterisation
Urine drainage bag emptying
La
tex
Nit
rile
La
tex
Nit
rile
Vin
yl
Do
me
sti
c
Do not wear gloves for:
Feeding residents
Routine bed making
Answering the telephone
Writing records
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22 6. S
harp
s m
an
ag
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Sharps containers
Should be the correct size according to usage.
Must be assembled correctly as per manufacturer’s
instructions, ensuring the lid is snapped firmly in place all
around the rim to avoid spillage or injury.
Must have the label dated and signed on assembly for
traceability purposes.
Must be located in a safe position that avoids spillage and
are at a height that allows the safe disposal of sharps.
They should not be placed on the floor.
Must be away from public areas and out of the reach of
children, to avoid accidents.
Must have the lid temporary closure in position after each
use, to prevent the risk of spillage.
Should not be shaken or the contents pressed down to
make room for more sharps or attempts to move or
retrieve an item from the sharps container.
Must be disposed of when the ‘fill line’ is reached, to avoid
sharps protruding from the opening, or every 3 months
even if not full, in accordance with NICE Guidance.
Containers awaiting disposal should be stored in a secure
location. They must be locked, dated, signed and the
location put on the label.
Must only be used for the disposal of sharps.
Note
The use of a needlestick or sharps injury
flowchart is good practice.
For further details visit:
www.infectionpreventioncontrol.co.uk.
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Guidance for Care Homes
27 7. B
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Use of disinfectant
Always use the appropriate personal
protective equipment (PPE), e.g.
disposable apron and gloves, and wear
facial protection if there is a risk of
splashing to the face.
Some disinfectants supplied as tablets
must be made up with the specified
amount of water using a diluter bottle in
order to achieve the correct concentration.
If the dilution of the chlorine-based disinfectant is incorrect
and a weak solution is used, any blood-borne virus, e.g.
hepatitis B, hepatitis C and HIV, will not be killed. If the
dilution is too strong, the equipment or surfaces may be
damaged.
Diluted chlorine-based disinfectant solutions become less
effective after 24 hours. When a solution is made, the
date and time should be recorded and the solution
disposed of after 24 hours.
To ensure that micro-organisms are killed, always leave
chlorine-based disinfectant solutions for 5-10 minutes
contact time or as specified on the container.
Do not use a chlorine-based disinfectant solution directly
on urine as toxic fumes will be released.
*Chlorine-based disinfectants may damage soft furnishings
and carpets. Detergent and warm water, carpet cleaning
machine or steam cleaner, should be used.
Note
Regularly check spillage kits, wipes and chlorine-based
disinfectant products to ensure they are within the expiry
date.
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Guidance for Care Homes
31 8. W
aste
man
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Note
Waste bins should be foot pedal operated with a lid.
Always use the foot operated mechanism to open the lid to
prevent hand contamination.
Waste bins in non-clinical areas, e.g. office, should have a
liner, but do not need to have a lid.
Sharps containers awaiting collection should not be placed
inside a waste bag.
Test your knowledge Please tick the correct answer True False
1. When handling tied bags only hold by the
neck.
2. Waste from a resident with a known or
suspected infection is ‘offensive’ waste.
3. Waste bins in clinical areas and toilets
should be foot operated with a lid.
4. Clear or opaque waste bags can be used
for domestic waste.
Remember
Offensive/hygiene waste: items contaminated with urine,
faeces, vomit, sputum, pus or wound exudate, from
residents with no risk of, known or suspected infection.
Waste stream guide note * Colour waste streams may vary depending on waste
contractors - check with your local contractor before implementing the waste stream guidance.
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A disinfectant product should be used that is bactericidal
and virucidal for the disinfection of equipment that has
been in contact with a resident with an infection, non-intact
skin, body fluids or mucous membranes, e.g. areas of the
body producing mucus, such as inside of the nose or
mouth.
Disinfectant products can be wipes, tablets or solutions,
e.g. Clinell Universal Wipes, Chlor-Clean tablets, Milton
solution. Some of which are chlorine-based, e.g. Milton.
If a chlorine-based disinfectant solution is used it should
be at a dilution of 1,000 parts per million (ppm).
If equipment is contaminated with blood or blood stained
fluid, a chlorine-based disinfectant solution at a dilution of
10,000 parts per million (ppm) should be used.
Sporicidal disinfectant
For residents with C. difficile it is extremely important that
a sporicidal disinfectant is used, e.g. Milton, Chlor-clean, to
clean equipment, as other non-sporicidal disinfectants will
be ineffective at killing the bacteria.
3. Sterilisation
Sterilisation is a specialist means of decontamination of
equipment. Items requiring sterilisation must be sent to an
accredited Decontamination Services Department.
Chlorine-based disinfectant solution
1,000 ppm available chlorine
When to use
1,000 ppm
On equipment in contact with an infected
resident, non-intact skin, body fluids (not
blood) or mucous membranes.
What to use (as per
manufacturer’s
instructions)
Sodium hypochlorite 2%, e.g. Milton
(dilution of 1 in 20, e.g. 50ml of Milton in
1 litre of water).
10. D
eco
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min
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of
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Inserting an invasive device, e.g.
urinary catheter.
If a resident is immunosuppressed,
diabetic or at high risk of infection.
Procedure for dressing a wound
Be ‘Bare Below the Elbows’ and
wash hands or use alcohol handrub.
Decontaminate the dressing trolley with detergent and
warm water or detergent wipes.
Collect dressing pack and equipment, check all items are
in date and packaging is intact. Place on the bottom shelf
of the dressing trolley.
Put on a disposable apron.
Loosen the adhesive or tape on the existing dressing.
Decontaminate hands again.
Open sterile dressing pack. Add any extra items without
compromising the sterile field.
Put on non-sterile gloves.
Remove the soiled dressing carefully, as a large amount of
micro-organisms can be shed into the air, and dispose of
the dressing appropriately.
Remove gloves and decontaminate hands.
Put on sterile gloves.
Perform the procedure, including cleaning of the skin
where applicable.
Maintain a sterile field throughout the procedure.
Dispose of all used items in a sealed bag and dispose of
appropriately.
Remove PPE and decontaminate hands.
12. A
sep
tic t
ech
niq
ue (K
ey t
op
ic)
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When to send a specimen?
For residents who are over 65 years, consider sending a
specimen if there are two or more symptoms of a UTI.
For catheterised residents, consider sending a specimen if
their temperature is less than 36°C or greater than 38°C, they
have a new or increased confusion or loss of diabetic control.
Specimen collection
Collect a mid-stream or ‘clean catch’ specimen.
If the resident is catheterised a sample should
be taken from the sample port not from the
drainage tap. Send a sample before starting
antibiotics. Use a specimen container with
boric acid (red top) as it preserves bacterial numbers for up to
72 hours. Fill with urine to the ‘fill line’ on the container.
14. P
reven
tin
g a
UT
I (K
ey t
op
ic)
Colours 1-3 suggest normal urine
1. Clear to pale yellow urine suggests that you are well hydrated.
2. Light/transparent yellow urine suggests an ideal level of hydration.
3. A darker yellow/pale honey coloured urine suggests that you may need to hydrate soon.
Colours 4-8 suggest you need to rehydrate
4. A yellow, cloudier urine colour suggests you are ready for a drink.
5. A darker yellow urine suggests you are starting to become dehydrated.
6. Amber coloured urine is not healthy, your body really needs more liquid. All fluids count (except alcohol).
7. Orange/yellow urine suggests you are becoming severely dehydrated.
8. If your urine is this dark, darker than this or red/ brown, it may not be due to dehydration. Seek advice from your GP.
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56 15. U
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cath
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(Ke
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True False Test your knowledge Please tick the correct answer
1. When emptying a catheter bag the
drainage tap should not touch the inside of
the container.
2. When removing a cap from a new catheter
bag tube, the end of the catheter should
not be touched.
3. Night bags are re-usable.
4. An apron and gloves are not required
when emptying a catheter bag.
Remember
When changing a catheter bag, to prevent contamination
and infection, do not touch the end of the catheter or tube.
Night drainage bags are single use.
Wear a disposable apron and gloves when emptying a
catheter or overnight drainage bag.
Note
If a care home does not have a bed pan washer and a
re-usable container is used for emptying the urine into, it
should be washed with detergent and warm water, dried
thoroughly with paper towels and disinfected with a
chlorine-based disinfectant solution (see page 36).
Catheter straps should be used to secure the catheter
tube to the leg to prevent trauma to the urethra. Ensure
the straps are positioned behind the tube on the leg bag.
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Guidance for Care Homes
59 16. V
iral g
astr
oen
teri
tis/N
oro
vir
us
2. Hand hygiene
Liquid soap and warm running water should be used by staff as
alcohol handrub is not effective at killing viral gastroenteritis.
Handwashing facilities including liquid soap and paper towels
should be available in each resident’s room for staff to use.
Encourage residents to wash their hands or use detergent hand
wipes to clean hands after using the toilet and before meals.
Visitors should wash hands on entering and leaving.
3. Isolation
Where possible, infected residents should be cared for in single
room accommodation until symptom free for 48 hours. If the
resident is unable to be isolated, e.g. due to dementia, staff
should, where possible, ensure the resident’s hands are washed
or detergent hand wipes are used to clean hands frequently.
Disposable aprons and gloves should be worn when in direct
contact with a resident who is symptomatic and when dealing
with diarrhoea and vomit. PPE should be removed, disposed of
and hands washed before leaving the room.
Affected care homes can re-open to new admissions when all
the residents are (a) symptom free for 48 hours and (b) a deep
clean of all affected and communal areas has taken place.
4. Decontamination
It is essential for environmental cleaning to be undertaken
during an outbreak at least twice daily to include all communal
items regularly touched by residents, e.g. hand rails, tables,
door knobs. These should be wiped with a hypochlorite
solution, e.g. Milton (see page 36). A fresh solution should be
made every 24 hours.
Toilets and commodes should be dedicated to residents who
have symptoms and cleaned after each use with a chlorine-
based disinfectant solution.
Wash laundry from an infected resident as infected linen.
Open windows to help remove the virus from the air.
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17. Clostridium difficile Clostridium difficile (C. difficile) is a spore-forming bacteria. It
is an important cause of infectious diarrhoea. C. difficile is
present in the bowel (gut) of 3-5% of people. Our ‘good’
bacteria (normal flora) keep the growth of C. difficile in
check. However, when antibiotics are given for an infection,
the antibiotics can kill off some of the good bacteria which
leaves room for C. difficile to multiply rapidly. The rapid
growth of C. difficile produces poisons (toxins) that cause
inflammation of the bowel and diarrhoea. Diagnosis can be
confirmed by laboratory testing of the resident’s stools.
Risk factors for C. difficile
People most at risk of C. difficile are usually those over the
age of 65 years and who have had any of the following:
Recent antibiotic treatment (within 3 months)
Recent hospital admissions
Previous history of C. difficile
Bowel surgery or laxatives
Proton Pump Inhibitor medication, such as omeprazole
What does C. difficile cause?
Offensive watery diarrhoea ranging from mild to severe which
may have blood in it, abdominal pain or tenderness, fever.
The illness can have serious consequences, including death.
How is C. difficile spread?
C. difficile can spread from person-to-person and can cause
outbreaks in care homes. It is spread mainly by:
Contaminated hands of residents and staff
Contaminated surfaces and equipment, C. difficile spores
can survive on surfaces for months or even years
17. C
lostr
idiu
m d
iffi
cile
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infection (bacteraemia). Signs of infection include fever,
redness, pain and increased wound discharge. Urgent
medical advice should be sought. If infection is present,
antibiotic treatment will be prescribed and suppression
treatment may be given.
MRSA screening
In accordance with Department of Health guidance, screening
is routinely undertaken by hospitals. Screening is not usually
required in a care home.
If a MRSA positive result is diagnosed after a resident has
been discharged from hospital, the GP will be informed, and if
appropriate will prescribe suppression treatment.
Suppression treatment
The aim of suppression treatment is to reduce the number of
MRSA bacteria to a less harmful level.
Treatment usually consists of a 5 day course of an
antibacterial body wash as well as a nasal ointment. At the
end of the 5 day course, swabs to check for MRSA clearance
are not usually required.
Management of a resident with MRSA
It is important to refer to your local policy for guidance. To
help reduce the spread of MRSA, standard precautions
should always be followed together with the following four key
principles:
18. M
RS
A
1. Communication
There is no justification for refusing to admit residents with
MRSA into any health and social care setting.
1. Communication 3. Isolation
2. Hand hygiene 4. Decontamination SAMPLE
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Written and produced by
Community Infection Prevention and Control
Harrogate and District NHS Foundation Trust
Tel: 01423 557340
www.infectionpreventioncontrol.co.uk
May 2018
© Harrogate and District NHS Foundation Trust, Infection Prevention and Control 2018
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